How Preventable Hospitalizations Can Shed Light on Health Equity | Healthiest Communities Health News

Early on in the pandemic, Alice Pressman noticed an alarming trend among Black patients at Sutter Health, the large Northern California health system where she is executive director of the Center for Health Systems Research. Compared with white patients, Black patients were nearly three times more likely to be hospitalized with COVID-19.

To respond to this type of disparity, Pressman and other Sutter researchers developed a data-based approach to vaccination: With an eye toward achieving herd immunity overall, the effort encourages practitioners to push specifically for even higher vaccination rates in at-risk populations, such as people of color.

This approach is focused on equity, rather than equality. And there’s a big difference between the two, Pressman says: Traditionally, research on equality in health care has centered on whether a patient population reflects the geographic population and whether the same level of care is being delivered to different members of that population.

“Equality is about what we do. It’s about the actions we take. Equity is about the result or the impact of those actions on the people we serve,” says Pressman, who is also scientific research director for Sutter’s Institute for Advancing Health Equity.

In tandem with this year’s Best Hospitals rankings, U.S. News & World Report developed measures aimed at capturing how effectively hospitals contribute to racial health equity in their communities, including an assessment that focuses on hospitalizations for conditions such as asthma, diabetes or high blood pressure. With adequate outpatient management, these types of “ambulatory care sensitive conditions” often do not require hospitalization, so examining such potentially preventable occurrences across racial groups can offer a window into possible disparities in preventive care.

Hospitals, of course, are often not the sole providers of preventive care, with outside physicians’ offices, clinics and community groups playing crucial roles in keeping people healthy. Yet the Affordable Care Act pushed tax-exempt hospitals to be proactive about community health, and hospitals can be penalized when patients are too recently readmitted for certain conditions, creating extra incentive for them to provide initial quality care.

Even beyond direct hospital care, potentially preventable hospitalizations help shed light on the physical and social conditions influencing health in a community.

“Geography really matters and access really matters. A lot of the racial and ethnic inequities that we observe in U.S. health care are also associated with the communities people are living in,” says Dr. Eric Schneider, senior vice president for policy and research at health care-focused foundation The Commonwealth Fund.

The Best Hospitals assessment compares the rates of potentially preventable hospitalizations among Black and non-Black Medicare beneficiaries in a given hospital service area, or HSA – a group of ZIP codes representing the community served by a hospital. Using data from 2015 – the most recent year this type of data was available by race – HSA discharge rates for Black beneficiaries with these conditions are also compared with the average discharge rate for all beneficiaries nationwide. HSAs are then placed into one of four categories based on their performance. They’re placed in one of three categories based on their performance over time.

Close to 400 HSAs were assessed on a community level, with a similar total assessed in comparison to the national average. Overall, 229 HSAs representing 645 hospitals landed in the best category available for at least one of the three preventive care metrics. Yet in more than 70% of the HSAs analyzed, Black beneficiaries were moderately to substantially more likely than non-Black beneficiaries to be hospitalized with these conditions.

A further U.S. News analysis shows that many communities in the South – such as the HSAs encompassing Lumberton, North Carolina, and Demopolis, Alabama – performed well in terms of providing equitable care, even as Black people there faced potentially preventable hospitalizations more than the nation as a whole. That’s likely because this type of measurement can capture the quality of care overall in an area as well as systemic inequity – and those two things can be difficult to untangle.

“Some states that have a low level of performance actually might end up looking like they have more equitable care,” Schneider says. “That’s because everybody is getting worse care.”

Using two states often on opposite ends of health-related rankings, Schneider offers a hypothetical example of a white person in Mississippi who might receive worse care than a Black person in Massachusetts. In other words, smaller gaps in care between racial groups don’t preclude a community from having worse care overall.

The opposite can be true as well: In two West Coast communities, for example – Berkeley, California, and Portland, Oregon – the data shows that Black people saw lower rates of potentially preventable hospitalizations than people nationwide. But compared with non-Black patients in the area, they were still being hospitalized for these conditions more.

In the Midwest, meanwhile, Black people often were worse off than both their non-Black counterparts in the same hospital service area and Americans served by hospitals elsewhere in the country.

The U.S. News assessment of preventive care offers a starting point for understanding health equity in hospital communities.

Not every community has a large enough minority population to draw accurate, quantifiable conclusions about health disparities, Schneider notes. For this reason, U.S. News excluded hospital service areas with fewer than 1,000 Medicare beneficiaries in either of the racial comparison groups.

Pressman points out that achieving equity also might require paying a disproportionate amount of attention to a smaller subgroup of a population, as with Sutter’s efforts to vaccinate racial minorities who face a greater risk from COVID-19. And in that case, it might not be a bad thing if a hospital or clinic is seeing a disproportionate number of Black patients walk through its doors: It could be an indication that Black residents in that area trust that hospital and choose to go there for care over other options, or that the hospital is doing something proactive to promote equity.

“Sometimes the work we do in equity just identifies places to look deeper,” Pressman says.

Schneider agrees that looking at equity measures, like disparities in preventable hospitalizations, are a start. But they have to be interpreted alongside other factors that influence community health, he says.

“A lot of the racial and ethnic inequities that we observe in U.S. health care are also associated with the communities people are living in, whether those communities are well-resourced,” Schneider says. “This is the concept of structural racism and the fact that where people live, work and play has a real strong influence on their health overall.”

It wasn’t until the advent of Medicare, in 1965, that hospitals were forced to desegregate. Today, safety net hospitals, which have less material resources than private hospitals, often serve more racial minorities, Schneider says.

“We may have overcome some of the segregation tendencies that existed within hospitals, but we’ve got a long way to go probably in terms of trying to desegregate or at least equally resource hospitals that are serving very different patient populations,” Schneider says.